Presented by:
Courtney Bennett, DNP, PMHNP-BC
Brenda Phillips, DNP, PMHNP-BC
 Demonstrate
understanding of neurocognitive
disorders.
 Identify neurocognitive subtypes and specific
syndromes.
 Recognize risk factors and treatment for
Delirium.
 Recognize treatment for Dementia.
 The
content of material presented
in this CE activity will not include
discussion of unapproved or
investigational uses of products or
devices.
 Attention
 Memory
 Language
 Orientation
 Praxis
 Problem
solving
 Delirium
 Mild
and Major Neurocognitive Disorder
(NCDs)
 KEY
POINTS
 1. Delirium is a disorder of attention and
cognition.
2. It has an abrupt onset and a variable
course.
3. It has an identifiable precipitant.
4. 1-year mortality rate is greater than 40%.
Read more: Delirium -Psychiatric Disorders- Cognitive Disordershttp://www.health.am/psy/more/delirium/#ixzz2PLzIvyYt
 The
essential feature of Delirium is a
disturbance of attention or awareness that is
accompanied by a change in baseline
cognition that cannot be better explained by
a preexisting or evolving neurocognitive
disorder (NCD) (DSM-5, p.599)
 May involve up to 50% of
hospitalized elderly patients. They
become acutely confused, agitated
and have an inability to sustain
attention.
 In elderly patients behavior changes
are often a first indicator of
delirium even in those diagnosed
with Dementia.
 Perceptual
disturbances
 Abnormal psychomotor activity
 Sleep cycle impairment
 Emotional instability
 Prevalence at hospital admission between 14
and 24 % ( source Kaplan and Sadock )
 Fluid
and electrolyte disturbances
(dehydration, hyponatremia,
hypernatremia).
 Infections (urinary tract, respiratory tract,
 Drug toxicity or withdrawal
 Hypoglycemia, hypercalcemia, uremia, liver
failure, thyrotoxicosis
 Low perfusion states (shock, heart failure)
 Postoperative states, especially in the elderly
 Medications (Anticholinergic)
 Acetylcholine..deficiency
 Dopamine..
excess
 Glutamate excitatory..excess
 Gaba inhibitory.. excess
 Serotonin..excess
 Ammonia secondary to hepatic
encephalopathy
 CABG
up to 35%
 Hip replacement up to 60%
 According
to the DSM-5, to diagnosis
delirium the individual should not be
in a coma and there should be a
level of arousal sufficient for
response to verbal stimulation (p.
600).
 Serum
electrolytes (Creatinine, glucose,
calcium, CBC, BMP or CMP)
 Drug Levels (Digoxin, lithium, or quinidine)
 Urinalysis and urine culture
 Blood gas
 Chest x-ray if indicated
 Substance
withdrawal delirium
 Medication-inducted delirium
 Delirium due to another medical condition
 Delirium due to multiple etiologies
 Other specified delirium
 Unspecified delirium
 When
the underlying cause of delirium is
identified, specific treatment is directed
towards the medical condition.
 Last about 7 days
 Milieu therapy
 Antipsychotics and benzodiazepines
 Agitation
will usually resolve once underlying
illness responsible for Delirium identified and
treated.
 Nonpharmacolgic interventions: Frequent
assurance and verbal orientation.
 Physical restraints: Only use as a last resort
Neuroleptic medications
 Haloperidol (Haldol) (0.5 to 1.0 mg)- Used to
control agitation or psychotic symptoms. 30
minute onset of action. Can be administered
orally, intramuscularly or intravenously.
 Monitor for extrapyramidal side effects (EPS)
(>4.5mg per day) and QT prolongation with
intravenous administration.
 Risperidone
(Risperdal) (0.5mg every 12
hours) can also be used to treat severe
agitation.
 Atypical antipsychotics have fewer side
effects and similar efficacy to haloperidol
(Seroquel, Geodon, Risperidone, and
Zyprexa).
Benzodiazepines
 It is recommended Benzodiazepines only be
used when neuroleptic drugs are
contraindicated.
 Primarily indicated for alcohol and sedative
drug withdrawal.
 Lorazepam (Ativan) (0.5 to 1.0mg)-can be
given PO (less restrictive) or IM and has a
rapid onset of action (5minutes).
 Always
monitor for EPS when prescribing any
neuroleptic (antipsychotic) medication.
 65
year old Caucasian male with a diagnosis
of Schizophrenia presents with complaints of
weird thoughts, hallucinations, and urinary
retention when he receives his Duoneb
Treatments. He has been stable on his
psychotropic medications for some time now.
1.What is the possible cause of his onset
of Delirium and why?
2.What type of Delirium would this be?

69 year old African American male presents with
increased confusion. Family reports episodes of
irritability, mood swings, hallucinations and the patient
reports feeling depressed. The family reports no sudden
life changing events that could have caused the
increased confusion. Laboratory results including
urinalysis are all within normal limits. The family
suspects Alzheimer’s Disease but after screening the
patient and interviewing the family the patient does not
fit the criteria for Alzheimer’s Disease. Upon
completing the assessment, the patient reports he is not
sleeping at night due to the neighbors making a lot of
noise. One of the family members laughingly states
“The way he snores I’m surprised he even hears the
neighbors”.
 73
year old Caucasian male presents with
increased delusions, auditory hallucinations,
and paranoia. He believes that people are
out to kill him and people have been
standing outside of his door watching him.
The nursing staff reports his psychosis
started all of a sudden, fluctuates during the
day, and he has become very withdrawn.
Upon assessment, you also notice he is now
receiving oxygen therapy for low oxygen
saturation and skin is grayish in color.

77 year old Caucasian male presents with his
wife who reports auditory hallucinations,
paranoia, and beliefs that people are trying to
harm him. She explains that he was in an
inpatient psychiatric facility for 28 days for
psychosis and was released two weeks ago on
antipsychotic meds and his symptoms have not
improved. She also reports unexplained weight
loss, memory loss, fatigue, progressive loss of
hair, and withdrawal that has occurred over the
last three months. A review of some of his lab
results reveals the following: WBC (4), RBC (3.9),
Platelet (375), SGOT (35), SGPT (65),
TSH (0.125).
 83
year old African American female presents
with a sudden change in mental status and
mood. Nursing staff reports she is confused,
irritable, refusing care hitting the staff, and
believes the nurses are trying to kill her. This
is a change from her baseline in which she is
usually pleasant and cooperative with staff. A
review of some of her labs reveals the
following: WBC (9), RBC (3.9), H&H (12 &
38), TSH (0.45), BUN(15), Crea (0.7)
Urinalysis: Cloudy urine appearance, WBC
urine >6, Leukocytes (+), Squam Epith >10.

KEY POINTS
1. Dementia is a disorder of memory impairment
coupled with other cognitive defects.
2. It has a gradual onset and progressive course.
3. It may be caused by a variety of illnesses.
4. Dementia predisposes to delirium.
Read more: Dementia -Psychiatric Disorders- Cognitive Disordershttp://www.health.am/psy/more/dementia/#ixzz2PLzi0Gea
 In
the DSM-5 the term Dementia
(newly named entity Major
Neurocognitive Disorders; NCD)
 Slowly evolving cognitive
dysfunction. Decline in thinking
skills
 Usually involves memory,
personality, information processing
 Gradual
loss of memory
 Problems reasoning
 Judgment
 Disorientation
 Difficult in learning
 Loss of language skills
 Decline in the ability to perform routine
tasks
 Can have changes in personalities and
behavior: hallucinations, delusions,
agitation, and anxiety.
Healthy Brain – Normal
Older Brain – Memory Loss
 Age
is leading risk factor( except for nun
study)
 About 20%of 75 year olds
 About 50% of those over 85
 Duration in years
 Few effective treatments except cognitive
enhancers
 Behavioral management can use
antipsychotics but there is a black box
warning
 The
prevalence of Neurocognitive Disorders
varies widely by age and by etiological
subtypes.
 Major NCD-Overall prevalence estimates for
dementia (which is largely congruent with
major NCD) are approximately 1%-2% at age
65 and as high as 30% by age 85 years.
 Mild NCD-ranging from 2%-10% at age 65 and
5%-25% by age 85
 Alzheimers
 Vascular
 Dementia
with lewy bodies ‘’visual
hallucinations
 Frontotemporal personality and behavior
(Pick’s disease ) sexually inappropriate,
aggressive
 Creutzheldt-Jakob disease (CJD)- “mad cow
disease”
 Dementia
attributable to Alzheimer’s disease
ranges from 60% to over 90%
 Vascular dementia estimates from 0.2% (6570 years age to 16% (80years and older) 20%30% are diagnosed with dementia within 3
months of stroke.
 Lewy bodies range from 0.1%-5% of general
elderly population and 1.7% to 30.5% of all
dementia cases
 Frontotemporal-20%-25% occur in older than
65
 The
first problem noticeable is forgetfulness
severe enough to affect their work, lifelong
hobbies or social life.
 Confusion
 Trouble with organizing and expressing
thoughts
 Misplacing things
 Getting lost in familiar places
 Changes in personality and behavior
 Alzheimer’s
disease advances at different
rates.
 The symptoms result from damage to the
brain’s nerve cells.
 Gradually gets worse as cells are damaged
and destroyed
 Total Care
 No one knows exactly what causes
Alzheimer’s disease
 Early
Stage- by the time it is obvious
someone has AD, it is too late to stop process
 Unable to recall major events and aspects of
their life
 Recognizable sign- someone gets lost while
driving to familiar place like grocery store
 Preparing a meal become difficulty
 Trouble concentrating
 Takes longer doing routine task dressing
 Middle
Stage- ability to perform basic
activities of daily living
 Develops deficits in daily hygiene (brushing
teeth, bathing, and eating independently)
 Forget own name or names of spouse,
children and others
 May not recognize themselves, family,
friends, or places
 Concentration, planning, and understanding
more difficult- make bad decisions
 Mood changes and behavior problems
 Keep
a routine
 One-step directions
 Limit noise and activity that can be
distracting
 Speak in gentle, low, slow voice
 Allow them to do what they can as long as
they can do it.
 Late
Stage- lose their ability to walk
independently
 Physical rigidity
 Physical deformities or contractures
 Death is inevitable until a cure is found
 Repeat
often
 Allows lots of time to respond
 Touch in a kind way
 Use touch with words to communicate
 Plenty of fluids
 Read or play music
Occurs when clots block blood flow to parts of
the brain, depriving nerve cells of food and
oxygen
Sometimes called “post-stroke dementia”
Forgetfulness may or may not be a prominent
symptom, depends on whether memory area
are affected
Difficulty focusing attention and confusion


Lewy bodies have been
found in several brain
disorders, including
dementia
Symptoms:
Memory problems
 Movement symptomsstiffness, shuffling walk,
lack of facial expression,
problems with balance
 Excessive daytime
drowsiness
 Life threatening to
Antipsychotic medication

 Disease
involving
Lewy Bodies
 Damaged and
destroyed cells in
brain area.
 Important in
controlling
movement
 Usually develop
dementia in later
stages of the
disease
 Rare
disorder chiefly affecting the front and
sides of the brain.
 Progresses more quickly than Alzheimer’s
disease and tends to occur at a younger age
 Changes in personality
 Judgment
 Planning and
 Social skills
 Show feelings disconnected from the
situation
 Rare,
rapidly fatal disease affecting about 1
millions people per year worldwide
 Usually affects individuals older than 60
 Symptoms




Impairment in memory, thinking, and reasoning
Changes in personality and behavior
Depression or agitation tend to occur early
Problems with movement may present from the
beginning or appear shortly after other symptoms
 Psychotic
features are common in many
areas of psychotic symptoms and depression;
particularly due to NCDs d/t Alzheimers
disease, Lewy body disease, and
frontotemporal lobar degeneration
 Mood disturbances, depression, anxiety and
elation may occur
 Agitation is common in a wide variety of
NCDs
 Apathy is common in mild and major NCD
 Statistically
the older the patient is, the
more likely they will develop a cognitive
disorder. Most people will be aware of
Alzheimer’s disease, as it affects around 4
million people in the USA alone. Alzheimer’s
dementia is a cognitive disorder.
 Organ
failure, infection, tumor, kidneys and
nerves disorder, side effects of medication
and drugs etc. which are some cause of
cognitive disorder.
 Awareness,
problem in perception,
reasoning, memory and judgment,
schizophrenia and delusional disorder these
are symptoms of this disorder.
 Risk
factor of this disorder such as advanced
cancer or other serious illness, having more
than one disease, dementia, and low levels
of albumin protein in the blood, infection,
taking medications that affect the mind or
behavior.
 Some
tips for treating this disorder for
example putting the patient in a quiet, welllit room with familiar objects, placing a
clock or calendar where the patient can see
it, reducing noise.
 Donepezil
(Aricept)
 Galantamine
(Reminyl)
 Rivastigmine
(Exelon)
 Memantine
(Namenda)
 May
slow the progression of mild cognitive
impairment to Alzheimer Disease
 May take up to 6 weeks before any
improvement in baseline memory or behavior
is evident
 May slow progression of disease, but does not
reverse the degenerative process
 Aricept
(Donepezil)- start 5mg/day; may
increase to 10 mg/day after 4-6 weeks
• Elderly may tolerate lower doses
 Monitor for bradycardia
 May lose effectiveness in slowing course of
AD after 6 months
 Once a day dosing
 Target symptoms- memory loss in AD and
other dementias , behavioral symptoms,
 One of only two drugs indicated for
moderate to severe AD
 Galantamine
(Razadyne)- Initial 4 mg twice
daily; after 4 weeks may increase dose to 8
mg twice daily then 12mg after 4 more
weeks
 Syncopal episodes associated with use of
medication
 May slow the progression of mild cognitive
impairment to AD
 Useful for DLB, Vascular Dementia
 Exelon
–(Rivastigimine)- Initial 1.5 mg twice
daily; increase by 3 mg every 2 weeks titrate
to tolerability; maximum dose to 6 mg daily
 transdermal – Initial 4.6 mg/24hours; after 4
weeks increase to 9.5/24hours; max 13.3/24
 Caution with renal, hepatic, and cardiac
impairment
 May interact with anticholinergic agents
 Treats behavioral and physichological
symptoms
 Namenda
(Memantine)- NMDA- may takes
months before stabilization
 Initial- 5mg/day; may increase by 5 mg each
week; max 10mg twice/day; over 5 mg
should be divided.
 Long half-life
 Unproven to be effective in mild to moderate
AD
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American Psychiatric Association (2013).
Diagnostic and Statistical Manual of Mental
Disorders (5th ed). Arlington, VA: American
Psychiatric Association.
 Godara, H., Hirbe, A., Nassif, M., Otepka, H. &
Rosenstock, A.(2014). The Washington Manual of
Medical Therapeutics. St. Louis, MI: Lippincott
Williams & Wilkins.
 Stahl, S. M. (2014). Essential
Psychopharmacology Prescriber’s Guide (5th ed).
New York, NY: Cambridge University Press.
 Townsend (2015). Psychiatric Mental Health
Nursing: Concepts of Care in Evidence-Based
Practice (8th ed). Philadelphia, PA: F.A. Davis
Company.
